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    33 views2 pages

    Deltavision Patient Encounter Form / /: Self Spouse Child Treatment Date (MM / DD / Yyyy)

    Uploaded by

    Jay

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    DELTAVISION PATIENT ENCOUNTER FORM

    PRIMARY ENROLLEE NAME (LAST, FIRST) SELF SPOUSE CHILD TREATMENT DATE (MM / DD / YYYY)

    / /
    PRIMARY ENROLLEE ID GROUP NUMBER DELTAVISION FACILITY NUMBER:

    PATIENT NAME (LAST, FIRST) OFFICE / PROVIDER NAME:

    Srvs Proc Eye Mbr Srvs Proc Eye Mbr Srvs Proc Eye Mbr
    Units Code Description Srvs L R Chrg Units Code Description Srvs L R Chrg Units Code Description Srvs L R Chrg
    EXAMS, FITTINGS & VISITS SINGLE VISION, PER LENS (continued) TRIFOCAL, PER LENS (continued)
    Routine Examination SV spherocylinder, +/- 7.25 to 12.00D sphere TF spherocylinder, +/- 4.25 TO 7.00D sphere
    92002 Intermed exam, New patient V2111 0.12 to 2.00D cylinder V2307 0.12 to 2.00D cylinder
    92004 Comp exam, New patient V2112 2.12 to 4.00D cylinder V2308 2.12 to 4.00D cylinder
    92012 Intermed exam, Estab patient V2113 4.25 to 6.00D cylinder V2309 4.25 to 6.00D cylinder
    92014 Comp exam, Estab Patient SV spherocylinder, over 12.00D sphere V2310 Over 6.00D cylinder
    92015 Refraction V2114 Sphere over +/- 12.00D TF spherocylinder, +/- 7.25 to 12.00D sphere
    Contacts - Evaluation & Fitting Other Single Vision codes V2311 0.12 to 2.25D cylinder
    92310 Fitting of contact lens V2115 Lenticular (myodisc) V2312 2.12 to 4.00D cylinder
    CONTACT LENS, PER LENS V2118 Aniseikonic lens V2313 4.25 to 6.00D cylinder
    PMMA (Hard contact Lens V2121 Lenticular lens, SV TF spherocylinder, over 12.00D sphere
    V2500 PMMA spherical BIFOCAL (BF) LENS, PER LENS V2314 Sphere over +/- 12.00D
    V2510 PMMA toric/prism ballast Bifocal Sphere Other Trifocal Codes
    V2502 PIMMA bifocal V2200 plano to +/- 4.00D V2315 Lenticular (myodisc)
    V2503 PMMA color vision defcncy V2201 +/- 4.12 to 7.00D V2318 Aniseikonic lens
    Other Contact Lens V2202 +/- 7.12 to 20.00D V2319 Trifocal seg over 28mm
    V2510 Gas permeable spherical BF spherocylinder, plano to +/- 4.00D sphere OTHER SPECTACLE CODES, PER LENS
    V2511 GP toric/prism ballast V2203 0.12 to 2.00D cylinder Other Lens Types and Materials
    V2512 Gas permeable bifocal V2204 2.12 to 4.00D cylinder V2410 SV variable sphericity
    V2513 GP extended wear V2205 4.25 to 6.00D cylinder V2430 BF variable sphericity
    V2520 Hydrophilic spherical V2206 over 6.00D cylinder V2499 Variable sphericity, other
    V2521 Hydorphillic toric/prism bllst BF spherocylinder, +/- 4.25 TO 7.00D sphere V2700 Balance lens
    V2522 Hydrophilic bifocal V2207 0.12 to 2.00D cylinder V2710 Slab off prism
    V2523 Hydrophillic extended wear V2208 2.12 to 4.00D cylinder V2715 Prism
    V2530 Scleral, gas impermeable V2209 4.25 to 6.00D cylinder V2718 Press-on lens, (fresnell)
    V2531 Scleral, gas permeable V2210 Over 6.00D cylinder V2730 Special base curve
    S0500 Disposable contact lens BF spherocylinder, +/- 7.25 to 12.00D sphere V2780 Oversize lens
    S0514 Color contact lens V2211 0.12 to 2.25D cylinder V2781 Progressive lens
    FRAMES V2212 2.12 to 4.00D cylinder Polycarbonate & High Index (with lens code)
    V2020 Frames, original purchase V2213 4.25 to 6.00D cylinder V2782 1.54-1.65, plastic
    V2025 Deluxe frame BF spherocylinder, over 12.00D sphere V2782 1.60-1.79, glass
    SINGLE VISION (SV) LENS, PER LENS V2214 Sphere over +/- 12.00D V2783 1.66 index or greater,plastic
    Single Vision Sphere Other Bifocal Codes V2783 1.80 index or greater, glass
    V2100 plano to +/- 4.00D V2215 Lenticular (myodisc) V2784 Polycarbonate-additional
    V2101 +/- 4.12 to 7.00D V2218 Aniseikonic lens Tints, Coatings & Miscellaneous Codes
    V2102 +/- 7.12 to 20.00D V2219 Bifocal seg over 28mm V2744 Tint, photochromatic
    SV spherocylinder, plano to +/- 4.00D sphere TRIFOCAL (TF) LENS, PER LENS V2745 Tint, any color, solid/grad
    V2103 0.12 to 2.00D cylinder Trifocal Sphere V2750 Anti-reflective coating
    V2104 2.12 to 4.00D cylinder V2300 plano to +/- 4.00D V2755 Ultra-violet lens
    V2105 4.25 to 6.00D cylinder V2301 +/- 4.12 to 7.00D V2756 Eye glass case
    V2106 over 6.00D cylinder V2302 +/- 7.12 to 20.00D V2760 Scratch resistant coating
    SV spherocylinder, +/- 4.25 to 7.00D sphere TF spherocylinder, plano to +/4.00D sphere V2761 Mirror coating, any type
    V2107 0.12 to 2.00D cylinder V2303 0.12 to 2.00D cylinder V2762 Polarization, any material
    V2108 2.12 to 4.00D cylinder V2304 2.12 to 4.00D cylinder V2770 Occluder lens
    V2109 4.25 to 6.00D cylinder V2305 4.25 to 6.00D cylinder REPORT OTHER CODE OR MODIFIER
    V2100 over 6.00D cylinder V2306 Over 6.00D cylinder

    FRM_0021_Patient Encounter Form_4.1.2013


    DELTAVISION PATIENT ENCOUNTER FORM

    Please complete all necessary information. Any encounter form with missing information (such as eye
    identifier, enrollee's ID number, etc.) will be sent back to your office for completion.
    1. Refer to the eligibility list to complete the top portion of the form.
    2. List all procedures or services (exam, frames, lenses, tints, etc.) initiated and/or completed at a given
    visit on one form by:
    a. Finding the applicable listed service on the form.
    If a service is not listed, you may enter the code and description in the blank field in the lower
    right corner of the form.
    b. Indicating the eye(s) for which the lens or other service was provided by circling "L" for the left
    eye; "R" for the right eye; or "L" and "R" for both eyes. Indicating the eye treated is not
    applicable or necessary for some listed vision services.
    c. Entering the number of "Units" dispensed or provided under that column.
    d. Listing any applicable charges to the patient, including non-covered services.

    Example: If, after a comprehensive new patient examination, the patient receives new
    spectacles with:

    Standard frames at no cost;


    Single vision lenses for both eyes (left eye, spherocylinder lens +4.25D
    sphere and +4.00D cylinder; right eye, spherocylinder +6.00D sphere and
    +6.00D cylinder) at no cost; and
    The lenses are polycarbonate, which have copayments of $25 per lens.

    Then, the provider's encounter form should show the following under:

    “Routine Examination”
    Srvs Proc Eye Mbr
    Units Code Description Srvs L R Chrg
    1 92004 Comp exam, New patient $0

    “FRAMES”
    1 V2020 Frames, original purchase $0

    “SV spherocylinder, plano to +/- 4.00D sphere”


    2 V2105 4.25 to 6.00D cylinder X X $0

    “Polycarbonate & High Index (with lens code)”


    2 V2784 Polycarbonate-additional X X $50

    3. Submit completed forms to DeltaVision no later than the first week of the month following
    treatment.
    4. Please do not fold each individual form when mailing.
    5. Mail all completed forms directly to:
    Encounter Processing & Provider Compensation /PC740
    P.O. Box 1810
    Alpharetta, GA 30023

    FRM_0021_Patient Encounter Form_4.1.2013

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